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Get AL Preparticipation Physical Evaluation Form 2010-2024

ALABAMA HIGH SCHOOL ATHLETIC ASSOCIATION Preparticipation Physical Evaluation Form History Name Sex Age Address School Grade n DD 0 J JLI D Date Date of Sport J o J I hereby state that to the best of my knowledge ILl L. J 00D Yes my answers to the above questions are correct. Signature of athlete Signature of parent/guardian Rev* 2010 Phone No skin problems itching rashes staph MRSA acne When was your first menstrual period Do have had any abeen medical ongoing heat hospitalized or muscle conditions cramps spent injury a since night like inDiabetes abees last hospital evaluation Asthma Have ever told sickle cell trait concussion Are you presently taking medications pills prescription with eyes vision use trouble passed special allergies breathing out equipment medicine during do pads after pollens cough braces exercise foods neck rolls mouth other activity stinging guard insects etc* infectious mononucleosis diabetes Has doctor restricted/denied in sports sprained/strained dislocated fractured broken or over-the-counter repeated swelling ordiseases Knee Ankle Explain answers below Foot Wrist Finger JThigh JShin Forearm DShoulder Hand DHip Head Back period your periods last year surgery What the longest time between birth FORM 5 IDUPLICATE AS NEEDEDI Page 1 of 2 a*. I- 0 ormal Physical Evaluation Rule 1 Sec* 14 - In order for a student to be eligible for interscholastic on file in the Superintendent s the student or D. O. the student is fully able to participate requirement Abdominal BP N -y-Pulse Musculoskeletal Pulses -/Genitalia males Weight Cardiovascular athletics there must be physician s statement has passed a physical exam and that in the opinion AHSAA Physicians Certificate Physical Examination or Principal s office a current in interscholastic ofthe certifying athletics Grade s 7-12. The Form 5 must be used* A physical exam will satisfy the for one calendar year from the date of the exam* Corrected L 20 / t. J w i Abnormal Findings HeightNeck Other Elbow E*N*T* Heart Skin Lungs Clearance A. Cleared B. Cleared after completing evaluation/rehabilitation C. Not cleared for Collision o Contact o Noncontact for Strenuous Moderately strenuous that examining physician M. J 00D Yes my answers to the above questions are correct. Signature of athlete Signature of parent/guardian Rev* 2010 Phone No skin problems itching rashes staph MRSA acne When was your first menstrual period Do have had any abeen medical ongoing heat hospitalized or muscle conditions cramps spent injury a since night like inDiabetes abees last hospital evaluation Asthma Have ever told sickle cell trait concussion Are you presently taking medications pills prescription with eyes vision use trouble passed special allergies breathing out equipment medicine during do pads after pollens cough braces exercise foods neck rolls mouth other activity stinging guard insects etc* infectious mononucleosis diabetes Has doctor restricted/denied in sports sprained/strained dislocated fractured broken or over-the-counter repeated swelling ordiseases Knee Ankle Explain answers below Foot Wrist Finger JThigh JShin Forearm DShoulder Hand DHip Head Back period your periods last year surgery What the longest time between birth FORM 5 IDUPLICATE AS NEEDEDI Page 1 of 2 a*. I- 0 ormal Physical Evaluation Rule 1 Sec* 14 - In order for a student to be eligible for interscholastic on file in the Superintendent s the student or D. .

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